HL7 Care Plan and Ordersets HL7 Patient Care Q3,4 Discussion

1. HL7 Care Plan and OrdersetsHL7 Patient Care Q3,4 Discussion

2. Meeting Goal • Goal: • Define a go forward plan to create a standard for the plan of care that integrates efforts within HL7 and across industry (IHE) • Why is this important? • Standardization needed to support care coordination, safety and quality • Interoperability is essential • There are relatively no standards related to the representation and transmission of plan of care information • Meaningful use

3. Agenda Four Questions: • What is a plan of care? • What efforts are underway to standardize the plan of care? • What’s the go forward plan? • Who is interested in working on this?

4. Project Summaryalso definition of the Plan of Care • The Care Plan structure is used to define the management action plans for the various concerns identified for the target of care. • It is the structure in which the care planning for all individual professions or for groups of professionals can be organized, planned and checked for completion. • Communicating explicitly documented and planned actions and goals greatly aids the team in understanding and coordinating the actions that need to be performed for the person. • Care plans also permit the monitoring and flagging of unperformed activities and unmet goals for later follow up.

5. Efforts Underway • IHE • HL7 (started in 2007 but nothing since then) • CDA / CCD • HITSP/C83 Section 2.2.1.24 Plan of Care

6. Efforts Underway • IHE • HL7 (started in 2007 but nothing since then) • CDA / CCD • HITSP/C83 Section 2.2.1.24 Plan of Care • SKMT – source of definitions to inform this effort

7. Definitions (HL7 Updates 2007) • A care plan(plan of care) is an ordered assembly of expected or planned actions, including observations, services, appointments, procedures and setting of goals, usually organized in phases or sessions, which have the objective of organizing and managing care activity for a target of care. • A guideline is ***** • Care plans are often focused upon one or more concerns, with the expected of one or more favorable outcomes. • Care plans may include orders sets as actionable elements, usually supporting a single session or phase. • A Care Plan is instantiated for a target of care based on characteristics of the target of care. • An order set or action request set is a pre-filled ordering template, or electronic protocol in which a set of actions are ordered or requested.

8. Efforts Underway • IHE • HL7 (started in 2007 but nothing since then) • CDA / CCD • HITSP/C83 Section 2.2.1.24 Plan of Care

9. HL7 Plan of Care Efforts

10. Project Summary • The Care Plan structure is used to define the management action plans for the various concerns identified for the target of care. • It is the structure in which the care planning for all individual professions or for groups of professionals can be organized, planned and checked for completion. • Communicating explicitly documented and planned actions and goals greatly aids the team in understanding and coordinating the actions that need to be performed for the person. • Care plans also permit the monitoring and flagging of unperformed activities and unmet goals for later follow up.

11. Storyboard Storyboard: Pneumonia Care Plan Generation: Purpose: This storyboard illustrates a pneumonia care plan containing Problems, Orders/Interventions and Expected Outcomes. Precondition: Med surg nurse admits Mr. Everyman, an 86 year old male, with an admission diagnosis of RLL pneumonia. He was seen in an urgent care clinic with complaints of a recent onset chest discomfort, shortness of breath upon exertion and general malaise. A CXR done in the clinic showed pneumonia. Dr. X (the family practice physician seeing the patient in the clinic) has written (paper) admission orders, and assigned an admitting diagnosis of RLL pneumonia. • The following orders are placed by the physician: • Admit to general Medicine • Service of Dr. X. • Diagnosis: RLL Pneumonia • Condition:Stable • Vital Signs q4h IV NS at 75cc/hr. Regular Diet as tolerated Activity as tolerated • Notify me if temp above 101 degrees F. Rocephin1 gm IV q 24 hours • CBC in AM CXR in AM Blood Cultures if temp above 101 degrees F. • Oxygen per nasal cannula at 3 liters per minute Maintain oxygen saturation >90%

12. Storyboard (continued) ADT information is in the system. The unit clerk enters the dx inform the admitting orders “RLL Pneumonia” A guideline for pneumonia exists in the system. Events: The nurse logs into the system and sees the following problems are suggested based upon the Pneumonia guideline: (Need to do activity diagram) • Risk for hypoxia (Observation of “Hypoxia” with Mood Code of “Risk”) • Risk Ineffective Airway Clearance • Risk for Falls related to low oxygen saturation Susan – check Risk of in TermInfo Discuss Risk/Event Moods with Problem modeling She selects the above problems which places them on the problem list and adds: Fluid Volume Deficit risk The following nursing orders are suggested by the system based on the selected problems and physician admitting orders. • Out of bed with assistance (linked to risk of falls) • Monitor I&O (intervention linked to all IV fluid orders) • Educate regarding I&O (linked to IV fluid orders) • Educate regarding OOB with assistance (linked to fall risk, linked to hypoxia) • Monitor oral/nasal mucous membrane status (linked to oxygen administration via NC)

13. Storyboard (continued) Nurse Sees suggested Goals/Expected Outcomes • Maintain oxygen saturation >90% (risk for Hypoxia) • Maintain Hydration (linked to Oxygen administration) (Susan – check this outcome) • No falls (Linked to Falls Risk) • Patient understands pneumonia disease process • Temperature WNL within 48 hours. • CXR reveals decreased consolidation in RLL. Nurse accepts suggested goals/expected outcomes and adds the individual goal: • Maintain Nutrition Post-condition: • Patient normothermic, decreased consolidation revealed by CXR, oxygen saturation greater than 90% on room air. Patient discharged to home on

14. Care Plan Model • http://wiki.hl7.org/index.php?title=Care_Plan_Model

15. Go Forward Plan • Create a project scope statement